What’s app: +66 819892565​

What’s app: +66 819892565​

Medical Inquiry Form​

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Contact Information​

First Name​ :

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E-mail Address :​

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Phone :​

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Address :​

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Address2 :​

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City :​

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State :​

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Zip/Postal Code :​

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Country :​

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Emergency Contact Information​

Last Name :​

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First Name​ :

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E-mail Address :​

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Phone :​

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Address :​

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Address2 :​

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City :​

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State :​

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Zip/Postal Code :​

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Country :​

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Requested Procedure​

(Please provide us with as much detail as possible).​

Please tell us which procedure you are interested in receiving:​

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Why are you interested in receiving the above procedure?​

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(Please be as honest as possible when responding to the above question - it is important that the doctor truly understands the purpose).    

General Information/Statistics​

Gender​ :

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( Please specific )​

Height :​

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Centimeter​

Weight :​

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Kilogram​

Date

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Date of Birth ​​

Month​

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Year​

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Medical Conditions​

Are you/have you ever had:​

Aids or HIV positive :​

Yes
No

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Anemia :​

Yes
No

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Arthritis :​

Yes
No

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Asthma :​

Yes
No

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Back Problems :​

Yes
No

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Blood Clots :​

Yes
No

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Blood Disorders :​

Yes
No

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Blood Disorders :​

Yes
No

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Cancer :​

Yes
No

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Bleeding Problems ​:​

Yes
No

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Chest Pains :​

Yes
No

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Colitis :​

Yes
No

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Depression :​

Yes
No

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Diabetes :​

Yes
No

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Ear Problems :​

Yes
No

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Eye Problems :​

Yes
No

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Epilepsy :​

Yes
No

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Heart Problems  :​

Yes
No

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Eye Problems :​

Yes
No

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Hepatitis :​

Yes
No

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High Blood Pressure :​

Yes
No

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Heart Problems  :​

Yes
No

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Irregular Heartbeat :​

Yes
No

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Stroke :​

Yes
No

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Any psychiatric conditions :​

Yes
No

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Migraine Headaches :​

Yes
No

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Seizures  :​

Yes
No

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Nose/Throat Problems :​

Yes
No

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Pneumonia :​

Yes
No

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Shortness of Breath :​

Yes
No

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Rheumatic Fever :​

Yes
No

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Stomach Problems :​

Yes
No

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Transfusion :​

Yes
No

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Thyroid Problems :​

Yes
No

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For Women Only​

Do you take birth control pills or any hormone replacement medication or patches? :​

Yes
No

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Are you pregnant ?​ :

Yes
No

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(Pregnant women must take a pregnancy test before departure as most pregnancies can disrupt surgery)​

Medical History​

In the past 18 months, have you been hospitalized, had surgery or received medical treatment, pregnancy delivery, or ambulatory surgery :​

Yes
No

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What was your date of surgery? :​

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What was your reason for surgery? :​

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Which procedure did you have? :​

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What was your net weight change since surgery? :​

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Do you have difficulty with healing or scarring? :​

Yes
No

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Have you had cosmetic surgery in the past ? :​

Yes
No

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If yes, please explain how your experience was : ​

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Please list any other past surgeries :​

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Medication​

Kindly list all the medication you take, along with the dosage: :​

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Are you allergic to any medication? :​

Yes
No

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If yes, please explain which medication(s) along with the reaction(s)​

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Have you had problems with anesthesia? :​

Yes
No

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Are you allergic to any type of food or latex? :​

Yes
No

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Do you take any vitamins or herbal supplements? :​

Yes
No

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If yes, please explain which ones :​

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Do you smoke ?​

Yes
No

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If yes, please explain which ones :​

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Do you drink alcohol ?​

Yes
No

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If yes, how much? Per day, per week, per month ?​

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